Heart-Related Deaths Prompt Changes

When George Boiardi died on March 17, the shock waves reverberated from one college campus to an entire sport. A senior captain on Cornell University’s men’s lacrosse team, Boiardi died after being struck in the chest by a ball late in a game against Binghamton University. If Boiardi had a chance to survive, everything was in place to make that happen: Athletic trainers responded immediately, an on-site AED was used, and EMTs arrived minutes later. Yet none of these efforts could save Boiardi.

Unfortunately, the lacrosse world was already familiar with this type of scene. Boiardi was the third collegiate lacrosse player in five years to die after being hit in the chest by a ball. One high school player also died the same way during that span.

The exact cause of Boiardi’s death will never be known because, at the request of his parents, no autopsy was performed. But the dangers of a blow to the chest are well known to medical professionals. The three previous lacrosse deaths were blamed on commotio cordis, which occurs when a non-penetrating blow to the chest directly over the heart during a very narrow phase of the heart beat causes ventricular fibrillation, or other types of arrhythmia, in an otherwise healthy heart. The vulnerable period is believed to last only 10- to 30-thousandths of a second.

Commotio cordis is believed to be very rare, although the exact number of cases is not known. The Commotio Cordis Registry in Minneapolis has documented more than 150 cases since it was formed six years ago and typically adds five to 10 more a year. But many past deaths likely went undiagnosed and other cases may still go undocumented.

The risk of commotio cordis extends far beyond lacrosse. Of the 128 cases recorded by the Commotio Cordis Registry through 2001, 62 percent occurred to participants in organized sporting events, ranging from youth sports to professional sports. Of those, 46 involved baseball or softball while 13 involved ice hockey. Five came in lacrosse.

High school and youth athletes appear to be most at risk as the average age of victims was 14 years old and nearly 80 percent of cases occurred in people under 18. Some researchers have attributed this to younger athletes having a more pliable chest wall.

In most cases, the speed of the ball or puck that caused the injury was typical for the sport and it was rarely hit or thrown particularly hard. When balls or pucks reach the highest speeds damage to the arteries and other areas of the heart becomes a danger.

In response to Boiardi’s death, the search for ways to reduce the incidence of traumatic heart deaths has accelerated. The US Lacrosse Sports Science and Safety Committee has recommended changing the rules of the game to penalize players who intentionally try to block shots by stepping in front of them. US Lacrosse Executive Director Steve Stenersen sent letters to both the NFHS and NCAA rules committee asking them to consider such a change.

But some college coaches aren’t waiting for governing bodies to act. “Hockey players dive in front of the puck all the time, but I’ve taken that type of thing out of my coaching repertoire,” says Dave Urick, Head Men’s Lacrosse Coach at Georgetown University. “It’s not something we now teach them or encourage them to do and that’s a direct result of what’s happened to these young men. I just felt like it made sense from a safety standpoint.”

Efforts are being made on the equipment front as well, with a focus on chest protectors. There is debate over whether chest protectors offer protection from commotio cordis: The Commotio Cordis Registry found that 28 percent of the deaths it recorded involving competitive athletes occurred to players wearing standard chest protection for their sport at the time, and some research on pigs found chest protectors to be ineffective.

However, in May, the National Athletic Trainers’ Association’s Age-Specific Task Force issued a statement on commotio cordis that suggested the use of all-purpose chest protectors during practices and games in sports where commotio cordis is a danger, including lacrosse, baseball, softball, ice hockey, and field hockey. The task force feels chest protectors may help in some cases, and thus may be one tool for prevention. Except for goaltenders, most lacrosse players do not currently wear chest protectors.

At the same time, researchers are looking for ways to make chest protectors that offer more protection from commotio cordis. The key will be finding a way to disperse the force of the impact over a larger area so that less of it is transmitted to the heart, thus reducing the chance of sending it into ventricular fibrillation.

Treatment of commotio cordis requires a quick response and an AED on site. The Commotio Cordis Registry reported that 25 percent of those who received resuscitative measures in less than four minutes survived while in 38 cases of delayed resuscitation only one person survived.

In many cases where a player has received a dangerous blow to the chest, any resuscitation efforts will prove futile, even if, as in Boiardi's case, they include an immediate response and an AED. But prompt proper treatment can increase the odds of recovery.

“Determine what the problem is as soon as possible, start CPR, and get an AED on that person right away,” says Keith Gorse, Clinical Coordinator in the Department of Athletic Training at Duquesne University and Chair of the NATA Age-Specific Task Force. “There’s a better than 50-50 chance of survival if you start caring for the person within a minute. But this means making sure there’s an AED on site—it can’t be 400 yards away.”